Is Non-Prescription Adderall Use Ethical, Even If It Works?

Lawrence DeGeest was Motherboard’s correspondent at the 2012 Society for Neuroscience Conference. Read his first dispatch here.

Hunter S. Thompson once said, “I hate to advocate drugs, alcohol, violence, or insanity to anyone, but they’ve always worked for me.” If only he were alive today so a neuroscientist could have a look at his brain. But in my experience, there are college students who make good proxies. Somewhere tonight there will be a undergrad holed up in the library who will try to synthesize half a semester’s worth of material (as yet not studied thanks to booze) the night before a midterm by grinding a pill of prescription speed given by a friend with ADD, perhaps, into a fine dust for intranasal administration. Should he be successful then eventually it will be difficult to separate his desire for an education from his appetite for drugs.

College students’ voracious appetite for study drugs like Adderall is widespread enough that it was one of the main topics of a marquee lecture on neuroethics at SnF 2012 called “The Impact of Neuroscience on Society: The Neuroethics of ‘Smart Drugs.’” If it were not so well delivered in the enormous, dim, and mostly empty convention ballroom, I would have inquired as to whether part of determining such drug ethics involved donating samples to the press whose ostensible business it is to know what is going on.

But there we were, listening to excellent stuff by Barbara Sahakian, faculty at Department of Psychicatry at the University of Cambridge. I have long suspected that plenty of neuroscientists, unlike, say, economists (my own particular field), harbor deep fascinations with drugs since they go straight to your brain and pull the levers all which ways. In any case, Sahakian was the perfect choice to lead a drug lecture. Her focus is nowadays, besides ecstasy – ravers who came to her lab were found to be prone to depression due to extreme weekend highs and subsequent weekday lows – on prescription drugs for diseases and conditions like Alzheimer’s, attention deficit hyperactivity disorder, and depression, with the fundamental goal of understanding the neural basis of dysfunction to develop better drugs. Specifically, she wants to create drugs with no risk for substance abuse which means drugs that have no effect on dopamine. But that morning she had grander things to address.

“I want to take you on a journey,” she began, lifting not a few curious eyebrows in the crowd. Others were unsurprised — probably they had been on a few journeys themselves. “A journey,” she continued, “that I’ve had about how my research as a neuroscientists has impacted on society and led me to think about how drugs may change the future of society.”

Her motivation for her research came when — what else? — a colleague offered her some pills.

“I was offered a cognitive enhancer by a colleague at a meeting in Florida some years ago, and that stimulated me to write this lecture. I had complained to my colleague that I was jet lagged, and he said do you want some of this?” she said.

“I started chatting with some people at the break. One person was on Adderall, one person was on Ritalin, they were taking all sorts of things. I thought, well this is interesting. Many academics were using these drugs and were receiving a global effect. They said it improved their mental energy and sustains hard thinking.”

Sahakian speaking in 2010. Via

This sort of use is rampant. Sahakian rattled off proof. The global share of modafinil, a narcoleptic treatment abused by people who want to stay awake, is $700 million, with 90 percent of use off-label. Nature conducted a poll that found that, out of 1000 respondents from sixty countries, 1 in 5 were using using cognitive enhancements. A New Scientist/BBC poll found similar results. The newspaper at the University of Cambridge informally surveyed campus to find one in ten students using stimulants.

“I thought it would be the neuroscientists who were using these drugs because they were learning about them and might be tempted to use them,” Sahakian said. “But it turns out it was the philosophers and English students, because they had to write these very long essays.”

Musicians, she says, have also told her that they use non-prescribed cognitive enhancers so they can perform a piece of music live with precision, or to enhance their emotional performance. Other people talk to her about seeking a competitive edge. This includes test-takers and athletes. The key connection among these users is a desire to focus attention at a critical time, sometimes believing they cannot do so under their own powers. Her studies have shown that healthy people feel more comfortable engaging in tasks with a cognitive enhancer than without.

IF THE PILL WORKS, TAKE IT

Working memory is that which is important to academic achievement. It is linked to fluid intelligence which is learning to learn, creative intelligence. It is also linked to crystallized intelligence, which is one’s IQ. Both have been found to be improved by cognitive enhancers in youth and adult subjects of low and high education. You get increased efficiency in the neural network employed by the task at hand – likely those in the prefrontal cortex.

“Your brain does not work as hard, yet you are getting a better performance,” Sahakian said. That is indeed efficiency, and it sounds great. And they may work across the board: a set of results from her laboratory show the effects of cognitive enhancers on people with disorders and healthy people are no different. So why not hand out capsuled motivation to everyone?

Sahakian started her lecture with a summary of findings from her lab on the effects of cognitive enhancers on patients with psychiatric disorders, and her project for the UK government stood out. Last year, one of the UK’s biggest productivity costs was due to absenteeism, where workers are basically too tired, depressed, or bummed to go into work. And while people are often taken care of when they’re physically ill, mental health can often take a back seat.

Biomarkers that signal the presence or potential of more severe conditions like Alzehimer’s and schizophrenia – many cases of schizophrenia, interestingly, are either developed or diagnosed among patients in their college years, according to Sahakian – are extant for depression too, which means they can be detected relatively early. Governments are investing into treatment and prevention research, not solely because neurophysicatric disorders distress patients, but also because they hurt productivity. Both are reasons she believes in cognitive enhancers.

“Cognitive enhancers exist to improve cognitive abilities in people with cognitive impairments,” she said. “And it’s been said that would reduce severe cognitive impairment by just one percent a year would cancel out estimated increases in long-term care costs due to our aging population.”

Perhaps this all sounds cold, but that’s research for you. To solve a problem you must first isolate it. This requires precise emotional processing, which Sahakian calls cold cognition, so you do not become like the doomed Lady Brett Ashley and Jake Barnes in Hemingway’s The Sun Also Rises, who as they drive away from Madrid think about how nice it would be if they could only be together.

At this point, you’re probably thinking about how great you could be if only your cognition was enhanced, just as it can be comforting to think that you can get through one test, or one period of feeling down, or any other low, through self-treatment. But that’s a fantasy. Sahakian made it clear that treating disorders with cognitive enhancements is done for specific purpose and not so that a healthy person can attempt to manifest an unhealthy fantasy of them self.

“While we can fairly well treat the psychotic symptoms of schizophrenia, the hallucinations and delusions with the anti-psychotic medications we have, people with schizophrenia are left with profound cognitive impairment, and those impairments stop them from rehabilitating,” she said. “Some can’t go back to work or to school.”

ADD and ADHD, for which around 70 percent of patients “respond favorably” to drugs, the remainder – which include patients for whom drugs are ineffective because they improve only say self-control but not working memory, or whose side-effects are too intense – face similar consequences without new treatments. About five percent of children of worldwide have ADHD. Fifty percent of children with ADHD keep it through adulthood.

“If we don’t treat severe ADHD, what happens is that unfortunately you have poor outcomes, including increased educational dropouts, joblessness, and criminal activity,” she said.

The true goal then of her research, fundamentally and briefly, is to repair the impaired. But doing so brings us to the discussion of how much repair is ethical when the repair can be disseminated to people who don’t actually need it.

WHAT ARE WE DOING TO OUR BRAINS?

There is one set of ethical problems dealing with patient diagnosis and treatment. Chief among them is whether administering neural protective agents to at-risk patients at different ages corrupts their development. It is one thing to take antidepressants in your twenties; many people do and it can be a good thing if properly managed and taken. Sahakian agrees. But if a child has high potential for adolescent or adult depression, should he be administered anti-depressants beforehand? Drugs for neuropsychiatric disorders are designed to treat what exists, but not to prevent what might. They may never, especially if people are concerned about their kids being doped up for no confirmable reason. And imagine if a government or another institution, like a church, began to prefer programmable human development over the organic variety.

The other ethical issue to prescribing neuro-enhancers is abuse. It is important to consider whether human nature tends towards extremes or regresses to a behavioral mean. There are drugs that take you to both places. Key then is determining whether there is an inherent human preference for extremism that demands normalizing drugs to diminish risk, or one for normalization that demands drugs to break away from the mean. But there is no certainty of either. People who want to be unique but also fit-in would be the best population to sample for study, but you would corrupt the study by forcing them one way or the other.

Sahakian nonetheless does know a great deal about healthy people abusing cognitive enhancers because they think it makes them better. There is substantial evidence that this is false. Take another Sahakian study. A group of medical students on hospital rotation, staying awake for past twenty-four hours, were administered a cognitive enhancer. Smart drugs are popular with doctors because there are no tremor affects like in caffeine. But the study found that the students did not perform their duties to patients any better or worse. A cognitive enhancer will not somehow make you a better doctor any more than it will make you a doctor. It will keep you awake and sharp for awhile, but that itself is poor logic for consumption since not even cognitive enhancements cannot reverse the diminishing cognitive abilities brought upon by sleep deprivation.

Sahakian also mentioned that many people who come into her lab report taking cognitive enhancers out of peer pressure or coercion. She says you can measure addiction by looking at neural physiology, but it is redundant when they come in and say they can’t stop, they don’t want any more but they can’t stop. These are the serious cases. Addiction to perfection is as real as that pill going down your throat.

Divisions abound on what is to be done. Some experts say that if people can boost their abilities to make up for what mother nature didn’t give them, what’s wrong with that? Others say that people shouldn’t be using these drugs because they’re designed for people with serious problems who really need help. So another question for the ethicists is whether cognitive enhancers will ultimately level the playing field or juice the opposing team.

Then there is the problem of illegal procurement. Partly to blame are over-diagnoses: patients may receive more than they need, giving them the opportunity to distribute their prescription. A similar situation happens when obesity is fought with Adderall prescriptions – one side effect is appetite reduction. Worse is online vending. Surveys find that many cognitive enhancers are bought online but their quality is not guaranteed, and they may be contaminated.

Sahakian wrote a handbook on neuroethics for her colleagues. At the University of Cambridge there is a clinic where young people came come in when they have unusual thoughts, or perhaps are hearing voices, so schizophrenia can be picked up early in order to protect their cognitive abilities. Likewise for other neuropsychiatric disorders. But there is much work to do and the problems will not cease.

“Treatment for those who need it desperately ought not to be held so it can be perfected to make sure those who don’t need it can use it without recourse.” “Life should be fair, but don’t take away my advantages.” “Who is to say how we should develop?” You can get all sorts of hot-blooded opinions on this sort of thing. But most of all I wondered about human will and what smart drug abuse may do to it. Then I remembered a note made earlier by Sahakian.

“There are other ways to enhance yourself,” she sad. “Learning generates new brain cells. Physical exercise is good for mood and cognition since it affects the hipppocampus.”

ABUSE OR NOT, PEOPLE NEED PILLS

I later headed to the press room, where Nora D. Volkow, psychiatrist and director of the National Institute of Drug Abuse and great-granddaughter of Leon Trotsky, was to be giving a chat. During a detour through the main galley where the posters hang, I noticed all the research on the brain on drugs. Like: “Dissecting Learning Processes Involved In Acquisition of Heroin Self-Administration.” Or: “Potent Effects of Hallucinogenic Drug Ibogaine On Adult Zebrafish.” (As it so happens, it was Hunter Thompson who first brought fame to Ibogaine by accusing 1972 presidential candidate Edward Musky of crippling addiction to it while on the campaign trail.)

Zebrafish are popular in neural science drug research, and this study folded into what a co-author referred to as the Zebrafish Neurophenome Project. Three independent presentations over three days were ultimately made at the conference, which is something of a coup. One presentation included a poster embedded with live-video of the impressive image techniques the authors developed to track swimming of intoxicated zebrafish to precisely identify drug effects. Staying at the top of the tank, nicotine makes them go in figure eights, LSD makes them go casually erratic, but Ibogaine makes them go straight to the bottom.

Volkow, via

But back to Dr. Volkow. Prescription drug abuse is getting most of the NIDA’s attention these days because people are increasingly dying from it. Still, much of the hour talk was unfortunately dominated by a radio man who apparently had come to the conference with a lengthy agenda concerning what he regarded to be the failures of scientists. Eventually, in a private moment, Volkow turned her thoughts to cognitive enhancement abuse by asserting that drugs should be made available to those who need them, even if abuse is possible.

“We don’t know depression at the molecular level, we don’t really know the neurobiology, and while we have many theories, in the meantime we develop medications,” she said. Essentially, the quandary is that psychiatric and psychological theory are slower than medication development. “You don’t want to wait until perfect knowledge, but you want to do something about devastating conditions now.”

She had words for the effect of cognitive enhancement abuse on emotional intelligence. She is in agreement with Sahakian that we simply do not know. But Volkow remembered a study she made in her clinic to see if people can respond negatively to overstimulation by dopamine – by being made to feel too good artificially. She gave normal people a high dose of an amphetamine and found that those whose neural scans indicated the highest dopamine levels found the feeling they got aversive and overwhelming. Only those with lower levels found it beneficial. So everything in moderation, right? Maybe. There is much left to know. That was all we could leave with.

Meanwhile, they are out there, the brains and the drugs and both of them together in sun and in shadows. That night, back on Bourbon Street, while standing outside with a beer to hear atmosphere from the bar, a local approached your correspondent and began telling jokes. “Those shoes on your feet, I know exactly where you got them. Oh you know that one? Ok, I’ll tell you how many children your father had. You ready? This is how many he had. None: your mother had all his children. Welcome to New Orleans folks. I got some coke if y’all want.”